Healthcare Provider Details

I. General information

NPI: 1336323542
Provider Name (Legal Business Name): GAROLD H HORN RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 01/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W CAMAS AVE
FAIRFIELD ID
83327
US

IV. Provider business mailing address

794 EASTLAND DR
TWIN FALLS ID
83301-6856
US

V. Phone/Fax

Practice location:
  • Phone: 208-764-2611
  • Fax: 208-764-2646
Mailing address:
  • Phone: 208-734-3312
  • Fax: 208-734-3313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH-1810
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: